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pection Report Number <br /> Waste Tire Su�& Inspection Repor <br /> R State of California � � I� >� <br /> CIWMB 181(New 04/04) Survey Form - Page 1 a , ; t <br /> California Integrated Waste Management Board -- - - - - - <br /> Part A.- Surve, BLUE OR BLACK INK PEN <br /> �. ��� ... . ----- <br /> 1 <br /> Inspection ype (Fill one) <br /> SiteSu <br /> ffix: 1 J 71 - -' f ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> TPID- <br /> { <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address T— i ", - f +- <br /> � f <br /> l_ "J <br /> Street <br /> Inspection Date T/ <br /> tarty Staatte Z rIIP Code Out <br /> Time I e OZ _In Time — <br /> Business Rep Title ®0 AM 0 AM <br /> PM ' 4 PM <br /> C0 T1171,111",7 <br /> Operational Status ire`Type Business Role <br /> M (Fill one only) (Fill all that apply) (Fill all that apply) <br /> Active Q,Passenget` Q Generator <br /> �k" w �areJ.a��.'..,�:�u._, e„a,J�;, �re' a«r E:3r✓���� ^�,� a,.' �. : , <br /> Latitude <br /> y 0 Closed AlTared ." ror, <br /> GPS I + 0 Hauler (� Indoor <br /> L - _ 'I i .._ 0 Inactive Truck, <br /> I , <br /> Rude - 77 FT 77i 0 End-Use 0 Contalin <br /> Longitude 0 Planned 0 OTR L <br /> Business;Type_(Fill all that apply) <br /> 0 New-Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Q Other i <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> Vj A HAULING AND MANIFEST REQUIREMENTS <br /> 0 00 Notice Of Violation 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) r` <br /> 0 0 - - - - - - <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 � 0 0 In Compliance - No Violations <br /> 0 0 Other: § -- -- <br /> Comments _ 4 <br /> iv <br /> , <br /> MR <br />_ t <br /> a, N <; " ,/' • A", <br /> " µ ."y .';";✓• -1 p • �a r 5, r. <br /> 1n°speict oh" orm ncluclET <br /> Comments Included::,0 -— µ tt _ ...y,�_ tpw <br /> b ' .,.,,..,.' t y„ '" ✓' I^r» r w*i ° <br /> Business Reps Signature- Phone Number/ _In Q ,.. . t <br /> _ --_ _ _.. \/ A;i�+ �' '� � �' . S .., <br /> INSTRUCTIONS ON BACK Correct:* ;Incorrect: 62081 <br /> , <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />